Interpretation of Symptoms and

Signs of Respiratory diseases

H.A.M. Nazmul Ahasan

Professor of Medicine
PMC
 Philosophy of a Physician
• ‘A man who has no philosophy is a bad philosopher’

• Medicine is the most scientific art and the most huministic science

• Doctors have close relationship with people even more than priests and lawyers

• Charaka (300-500 BC) outlined 6 qualities and 4 principles of a physician

– Having knowledge • Cordial towards the sick

– Critical approach • Sympathy towards the sick

• Interest in cases according to one’s
– Insight into allied sciences
capabilities
– Sharp memory
• No attachment with the patient after his
– Promptness
recovery
– Perseverance
Significance of Hippocratic Oath

• serve s as a lasting model for

– Professional integrity

– Conduct (460 – 370 BC)

– Philosophy
 Abu al-Hasan Ali ibn-e Raban Tabari
(807-861 AD)

in the book "the Paradise of Wisdom" (Ferdous al Hekmat) :

• personal characters of the physician,

• obligation towards patients,

• obligation towards the community,

• obligations towards his colleagues, and

• obligations towards his assistants

 The art & science of Diagnosis
• A detective work controlled by a system of logical analysis

• Every diagnosis is Based in 3 foundations: history, physical signs

and investigations

• Not lucky guesses

• Inspection is active search for evidence not just hurried glance

• Physical examination must be precise, standardized &

interpreted with appropriate criteria in order to achieve
uniformity and consistency
Lungs:
expands,
pulls air
during
inhalation,
exhale air
during
expiration

Lung is
stationary:
Air Sac
flows air
unidirectio
nally

No Lung,
Air flows
Through
out body
 Contents
• Introduction
• Cardinal symptoms
• Cardinal Signs
– Inspection
– Palpation
– Auscultation
• Clinical pearls from some diseases
• Take home message
 Introduction
• High index of suspicion on the basis of clinical information is
necessary to diagnose a disease even in very modern and
sophisticated investigation technologies

• There is no alternative of meticulous history taking and

physical examination to reach a diagnosis of any diseases
including respiratory diseases.

• This is equally important to medical students and clinicians at

any stage
 Cardinal Symptoms
• Cough

• Sputum

• Hemoptysis

• Chest pain

• Breathlessness
 Symptoms: Cough
• Duration:
• Diurnal Variation: Br Asthma, COPD
• Dry: Influenza, Pneumonia
• Productive: Lung Abscess, Bronchiectasis
• Paroxysmal Cough: Chr. Bronchitis, Bronchial Asthma
• Bovine Cough: Rec. Laryngeal Nerve palsy
• Painful Cough: Pleurisy, Pneumonia
• Cough with Stridor:Retrosternal goitre Diphtheria, Whooping
cough
 Prolonged Persistent Cough(>2months)
Common causes

• Chr Bronchitis

• Cough variant asthma

• Pulmonary Tuberculosis

• Bronchiectasis X-ray Negative causes of prolong

cough
• Bronchial Carcinoma

Less common • Chr Bronchitis

• GERD • Cough variant asthma

• Sarcoidosis in early state • GERD

• Sarcoidosis in early state

 Sputum
• Amount

– Profuse, Purulent, days to weeks: Lung Abscess

– Copious, long duration, recurrent, months to years:

bronchiectasis

• Colour:

• Odor :Foetid – lung abscess by Anaerobic organism

 Sputum
Types Characteristics Example

1 Serous Watery, Frothy, Clear Acute Pulmonary Oedema

2 Mucoid Thick, white Chr. Bronchitis, Chr. Bronchial Asthma

3 Purulent/ Yellow, green Lung Abscess, Bronchiectasis,

Mucopurulent Empyema thoracis with Bronchopleural
fistula
4 Rusty Altered blood Pneumonia

5 Hemoptysis Blood staining of sputum Pul. TB, Bronchiectasis, Lung Abscess,

Br. Carcinoma, Pul infarction, Mitral
Stenosis
6 Coloured Gray Excessive dust inhalation
Black Coal miner’s pneumoconiosis
 Hemoptysis Vs Hematemesis
Characteristics Haemoptysis Haematemesis

Definition Coughing out of Blood Vomiting out of Blood

Duration Days together episodic

Colour Bright red Altered, Coffee ground

frothy Yes No

Food material Absent May be present

Melaena Absent Present

Premonitory None Present

symptoms

Reaction Alkaline Acidic

Other symptoms Resp /CVS GIT/ Hepato-billiary

 Chest Pain
Types Characteristics Example
Pleuritic chest pain Usually unilateral, worse Pneumonia, Pulmonary TB, Pulmonary
on deep inspiration, infarction, Bronchial Carcinoma,
aggravated by cough, pleurisy
sneezing

Sudden severe chest pain Associated breathlessness Acute MI, Desecting Aneurysm,
Pneumothorax,

Central chest pain Acute MI, Angina Pectoris, Pericarditis,

Desecting Aneurysm,
Pneumothorax, Acute Tracheaitis
Reflux esophagitis, Hiatus Hernia,
Hyeterical

Unilateral chest pain Pneumonia, Pleurisy, Pul. Infarction,

Pneumothorax, Br. Carcinoma, MSK
Pain, Herpes Zoster
 Breathlessness
Definition: Difficulty in breathing reaches the level of consciousness

• Respiratory: • Others:
– Bronchial Asthma – Uremia,
– Pneumothorax – DKA
– Massive pleural effusion – Myasthenia
• CVS: – GBS,
– Acute pulmonary oedema, – Foreign Body in airway,
– Massive pulmonary – Diphtheria
embolism
 Acute Breathlessness
1. Severe acute asthma
2. Acute LVF
3. Tension pneumothorax
4. Massive pulmonary embolism
5. Conversion Disorder

Causes of PND
1. LVF
2. Chr Bronchial Asthma
3. COPD
 Central Cyanosis

Respiratory Cardiac
– Tension Pneumothorax
• Acute LVF
– COPD
– Severe Acute Asthma
– Severe Pneumonia
– Massive pleural effusion
– Interstitial lung Disease
– Pulmonary infarction
 Clubbing

Respiratory diseases Cardiovascular diseases

• Suppurative Lung Diseases • Congenital Cyanotic Heart

– Lung Abscess Diseases
– Bronchiectasis • Infective Endocardidtis
– Empyemqa Thoracis

Miscellaneous
• Bronchial Carcinoma
Inflammatory Bowel diseases
• Interstitial Lung Diseses
Coeliac Disease
 Other findings on General examination
• Neck: Lymphadenopathy: Bronchial Carcinoma

Sup. Venacaval obstruction: Br Carcinoma, lymphoma

• Anaemia: Bronchial Carcinoma

• Gynaecomastia: Bronchial Carcinoma

• Eyes: Hornors Syndrome (Partial Ptosis)

• Skin: Erythema Nodosum-Primary Pulmonary TB,

` sarcoidosis

• Skin Nodules: Br. Carcinoma

• Oedema: Cor pulmonale

 Examination of the Chest
Resp Rate: Increased: Ecercise, Excitement, fever, Pneumonia,
Acidosis
Type of respiration:
Abdominal
Abdominothoracic
Thoracic
Rhythm
Regular
Irregular: Chyne stokes Breathing
 Inspection

• Shape: Bilaterally Symmetrical (Ratio

5:7)

• Deformities:
– Increased Anterior : Posterior
Diameter

– Barrel Shaped Chest

– Kyphoscoliosis

– Pectus carinatum(Pegion chest)

– Pectus excavatum
 Inspection of Chest
• Indrawing of
– Suprasternal notch COPD
– Supraclavicular fossa Bronchial Asthma

– Intercostal space

• Intercostal Space fullness :

o Amoebic liver Abscess, Pl effusion,
• Scar mark of thoracotomy
• Swelling
 Chest movement
Unilateral restricted movement

– Pleural Effusion

– Pneumothorax

– Consolidation

– Collapse

– Fibrosis
 Palpation
• Movement: Bilaterally Symmetrical

• Expansion: reduced in emhysema

Pull: Fibrosis, Collapse
• Position of trachea
Push: Pneumothorax, Pl effusion
• Position of Apex beat

• Vocal vremitus: Increased: Consolidation, Cavitation

Decreased: Pleural effusion Pneumothorax

 Position of the trachea
No Push
Push No Pull Pull

• Tension • Pneumonia • Collapse

Pneumothorax • Bronchial Asthma • Fibrosis

• Massive Pleural • COPD

effusion • ILD

• Pulmonary
Tuberculosis
 Percussion note

• Normal

• Hyper resonant: Unilateral: Emphysema

Bilateral: Pneumothorax

• Dull- Impaired: Consolidation

• Woody dull, Stony Dull: Pleural effusion

 Auscultation
• Breath sounds:
Vesicular,
Vesicular with prolong in expiration
in Chr Bronchitis, COPD
Bronchial: consolidation
• Added Sounds: Rhonchi
Crepitations
Pleural rub
Stridor
• Vocal Resonance: Normal
Increased
Decreased
 Reduced breath sound

• Pl effusion

• Pneumothorax

• Emyema thoracis

• Neoplasm

• Pulmonary collapse
 Bronchial Breath sounds

• Common:

Pneumonic consolidation

Large cavity-Lung Abscess

Uncommon: At the top of pl effusion

Localized Pulmonary fibrosis with patent bronchi

Pulmonary collapse with patent bronchi

 Crepitations
Bilateral Creps: Unilateral Creps:

– Left Ventricular Failure – Pneumonia

– Bilateral Bronchiectasis – Lung Abscess
– Interstitial Lung Disease – Pulmorary
– Bronchopneumonia Tuberculosis(post tussive
– Extensive Bilateral Apical creps)
Tuberculosis
 Unilateral chest disease
• Pneumonia
• Pleural effusion
• Pneumothorax
• Collapse
• Fibrosis
• Mass lesion
• Bronchiectasis: Unilateral
• Pulmonary Tuberculosis: Unilateral
 Bilateral Chest disease
• Bronchial Asthma
• COPD
• Interstitial Lung Disease
• Pulmonary oedema
• Bronchiectasis: Bilateral
• Pulmonary Tuberculosis: BIilateral
 Pleural effusion and Pneumothorax
Pleural effusion Pneumothorax
Symptoms: Chest pain Present , dull aching More and acute
Breathlessness Present Present
Symptoms of underlying Present Present
disease

Physical Examination
Trachea Shifted towards opposite Shifted towards opposite
side side

Percussion Woody dull Hyper resonant

Breathsound Absent on affected side Absent on affected side

Vocal fremitus Decreased Decreased

Vocal resonance Decreased decreased
 Pneumonia
• Symptoms: Fever, Cough, chest pain
• Signs: febrile, herpes labialis
• Chest:
– Chest movement reduced in one side
– Percussion note dull
– Diminished Breath sound in affected area
– Bronchial Breath sound in affected area
– Crepitations in affected area
– Vocal fremitus & resonance increased
 Bronchial Asthma

• Prolong history of chough,wheeze &

Breathlessness
• Patients of all age
• Onset: Childhood/ young age
• History of allergy
• Family history positive
• Sign: Rhonchi and Wheeze
 COPD
• Cough, wheeze breathlessness
• In aged patients
• History of smoking
• Often PND
• Pink puffer or blue bloater
• associated cyanosis, respiratory failure
• Prominent accessory muscles of respiration
COPD
 Collapse Vs Fibrosis
Fibrosis Collapse

Course of illness long Acute

Chest movement Reduced unilaterally Reduced unilaterally

Flattening of the side Present Absent

Trachea Same side Same side

Auscultation Crepitation if bronchi is Bronchial breath sound over the

patent bronchus
Absent over the collapsed area
 ILD
• Progressive breathlessness

• Age more than 40 years

• Clubbing

• Cyanosis

• Fine crackles on both base of the lungs

 Bronchiectasis
• Prolong course of diseases

• Recurrent productive cough with copious purulent sputum,

hemoptysis, fever, toxic undernourished,

• Clubbing

• Bilateral coarse crackles

• May have receive anti TB drug regimen

 Lung Abscess

• Fever, cough, productive purulent sputum

• Acute onset
• Febrile toxic patient
• May have hemptysis
• Clubbing
• Bronchial breathsound
• Crepitations
 Bronchial Asthma vs Cardiac Asthma
Severe Acute Asthma Acute LVF (?Cardiac Asthma)

History Known pt of Bronchial Asthma for Known case of IHD, Valvular Heart
years disease, HTN

Symptoms Breathlessness, wheeze, cough, Breathlessness, palpitation, chest

mucoid sputum, fever pain, pink frothy sputum

Signs May be present May be present

Cyanosis

Oedema Absent Present

Pulse Pulsus paradoxus Pulsus alternans

supraclavicular, Prominent absent

suprasternal
recession,
Accesory muscles
of respiration
 Bronchial Asthma vs Cardiac Asthma cont.
Severe Acute Asthma Acute LVF
Rhonchi Over whelming few
Crepitations absent Bilateral basal
Apex beat Normal May be changed- LVH, Valvular Heart
disease

Auscultation Normal Evidences of heart valves

X-ray Chest PA Normal Evidences of Valvular heart diseases

ECG Normal MI, LVH, Arrhythmias

Treatment
Morphine Contraindicated given

Frusemide No help Helpful

Aminophylline often given Often harmful
 Chr. Bronchitis Emphysema Bronchial Asthma

Age of onset > 40 years Smoker, late Often in childhood

Family history of Uncommon Uncommon Common

Asthma
Personal History Uncommon Uncommon Common
of Allergy
Smoking Smoker Smoker Non-Smoker

Early Symptoms Persistent morning Breathlessness Paroxysms of

cough & sputum wheeze
Infective common Occasional Variable
episodes
Exercise Often reduced poor Often normal in
tolerance remission
Central cyanosis Common in late stage Absent Absent except
Blue & Bloated Pink puffer severe attack
Wheeze, Rhonchi Present Often inaudiable Present during
attack
Prognosis poor very poor good
 Clinical signs of respiratory diseases: Summery
Disease Movemen Mediastinal Percussion Breath sounds Added
t of the displaceme note sounds
chest nt
Pneumonic Reduced Nil Dull Bronchial Crepitations
consolidation

Pulmonary Reduced Towards Dull Reduced or Nil

collapse affected Absent
side Vesicular
Localized Reduced Towards Dull Vesicular Crepitations
fibrosis affected
side
Pleural Reduced Away from Stony Dull Reduced or Nil
effusion affected Absent
side
Pneumo- Reduced Away from Hyper absent Nil
thorax affected Resonant
side
 Take Home Message
• Diagnosis is a detective work controlled by a system of logical
analysis based on 3 foundations: history, physical signs and
investigations
• Symptoms & Signs hardly change over years
• Classical presentations are discussed here
• There may be atypical presentation
• Few routine investigations like CBC, ESR and X-ray Chest may affirm
the clinical diagnosis
 Acknowledgements

• Scientific committee, BSM

• Dr. Chandra Shekhar Bala FCPS (Medicine)

Jr. Consultant, NINS & H
আেরক
ফাল্�ন…
 March,1971

“..েযেনা ভ�েল না যাই, েবদনা পাই…”

Salute to National Heroes

Good Luck Bangladesh

 ধন�বাদ
Thank You